RG: We've gone through several changes over the years. Initially, we were looking at the whole array of complementary and alternative medicine techniques. The change we made moving from our initial medical director to my predecessor, Dr. David Servan-Schreiber, was to focus the center on specific techniques that were more amenable to scientific study and to develop research programs that would be able to test out these techniques. At the same time, our affiliation with the university became tighter. Even in our clinical practice we've tended to focus on the kinds of techniques that we'll be able to test out, or that have some scientific support. Since the clinical programs are under the auspices of the university and UPMC, they wanted to be sure that the programs that we were delivering and promoting were done in a way that was very credible. Dr. Servan-Schreiber worked with UPMC Shadyside and also developed liaisons with private foundations to support the academic mission, so I'm in the fortunate position of inheriting the program in such good shape. We're recruiting a research director who can get more research studies off the ground. We'd like at some point be able to get a fair amount of federal funding for the things that we're studying as opposed to relying on local foundation support.

RG: There are two physicians: myself and Dr. Amy Stein, who practices integrative and holistic medicines and she also has a general family practice. I'm a psychiatrist and also a physiatrist, and my primary specialty has been pain management. Between myself and Dr. Stine we cover a fair amount of medical, mental health and pain conditions that people would be presenting to a complementary clinic for services. We have one licensed acupuncturist as well as myself. We have about ten other clinicians, most of whom work on a contract basis with us and cover the gamut of complementary medicine approaches. We have a doctor of chiropractic, a massage therapist, someone who practices shiatsu, people who practice cranio-sacral therapy and therapists who practice reflexology. We have a clinician who's trained in bio-feedback and also a naturopath—a non-physician specialist who is trained in the use of herbs, dietary agents and supplements to treat various health problems and to treat disease. We have several clinicians who work with individuals one-to-one and we also have classes that are taught in meditation, relaxation and yoga. We also have two psychotherapists. Part of our philosophy is to help patients to find approaches that can be used along with standard medical treatment. For example, when we see psychiatry patients in our clinic, a lot of times it's because they haven't responded to the usual medications, so we may follow their medications and may also look at whether there are dietary or nutritional agents that could help in terms of their mood or other symptoms like sleep problems or anxiety. All patients that are seen in our clinic, before they even come here, need to be hooked up with a primary care physician. They don't necessarily come in by referral from their physician, although we certainly do appreciate physician referrals. If someone says that they don't have a primary care doctor, we'll give them names of doctors because we don't want to find ourselves in the position that someone's saying, "I'm not going to do anything having to do with medicine. I'm here to cure my cancer or my heart disease." Most patients have seen, not only their primary care physician, but other specialists for the problems they're coming here for.

RG: There are three terms that are used. Alternative medicine, which has the connotation that a person will use these approaches in lieu of western medicine techniques. Complementary medicine, which has the idea that one can avail themselves of nontraditional interventions in concert with standard medical treatments. And the third term, integrative medicine, has the mindset that treatments dovetail together very nicely, so that a physician may do laboratory studies or assessments about a patient's hormonal factors, may counsel the patient about nutrition and may refer the patient for psychological treatment for depression or sleep, or may refer them for acupuncture. The treatments overlap and it becomes somewhat arbitrary what you call alternative or complementary when you're working from that integrative model. Some people will call and say, "I would like to see the chiropractor" or "I'd like to see the acupuncturist," and they may not see the physician. That may be all that they need, so they would not get the full integrative approach. But people who have more significant or chronic problems may well be able to benefit from seeing the physician, seeing several of the clinicians here and then possibly doing some other kind of therapy.

RG: Things get lumped into complementary medicine just because they sound weird. But things that are standard medical treatments can move from one category to the other. A few years ago, if someone said, "I'm going to give you an antibiotic to treat your ulcers," you would have told that person they're crazy, that there's no way that antibiotics would make a difference for anything going on in the stomach where no bacteria could possibly live. People do surgeries or use medications that they've just always used because they seem to work, not because they've been subjected to any double-blind placebo controlled trial. So it becomes a little bit subjective why one treatment gets classified as complementary. Chiropractic is one area that's moving from the position of being well on the outside of medicine to where the research base shows benefit for medical conditions like acute lower back pain. Hypnosis is another area where there's been a lot of research done—that was at one time considered to be more of a complementary or alternative medicine approach and now is more part of the standard practice that psychologists or psychotherapists will use. The techniques that we have available at the center are essentially techniques that, by consensus, are not as much of a part of the traditional medicine approach. If I'm seeing a patient for pain at the center, it's going to be more of an integrative approach. The problems that people have when they come to the center are things that their physicians may be at a loss to help them with. For example, someone with chronic lower back pain: they've gone the route of surgery, of medication, of physical therapy. They're looking for whether there is something else out there that can enhance their quality of life without using tons of medication and feeling drugged. It's the idea that there are other modalities available that aren't part of our standard armamentarium of medicine that may well be helpful. The patients seem to be motivated to seek those out.

RG: I think those are legitimate concerns. What is occurring in other academic centers, what we're trying to get going here and what the National Center For Complementary and Alternative Medicine is trying to do is sponsor research to study each of the techniques that seems to be helpful. The first step with any treatment technique is to use it in practice and see if things seem to work. The next thing is to see if the treatment is really a fluke and subject it to more rigorous study. Complementary medicine techniques can be more difficult to test than some of the standard medical interventions. For example, if you're doing a medication trial, it's easy enough to give someone a placebo and there's not any way to really tell the difference from the active medication. But if you're doing a study for acupuncture, the patients can often figure out whether they are getting an active treatment or some type of placebo treatment, so the patient's expectation affects the outcome. There are ways to do an intervention like an acupuncture treatment so that a person wouldn't necessarily know which group they were in. You could compare two different treatments rather than a treatment and a placebo. To me it doesn't matter if it's a placebo effect or if it's a real effect if you're getting changes in someone's brain chemistry that are health-promoting. If you had a pill that did the same thing you'd said that's great too.

One approach would be having someone undergo an acupuncture treatment and looking at the effect on functional neuro-imaging—PET scans or functional MRI—so that you see where it is in the brain that you're having the effect, because we already know quite a bit about how the pain message is processed. If you see a change in the activity of brain centers that keep the pain message going, then even if this is a nonspecific effect of needling, you're changing physiology and it's a beneficial thing for the person and takes it beyond the idea of a placebo. For other techniques like some of the mind-body approaches, we'll have the resources in a few years to be able to look at what effect those approaches have on health and disease. For example, people who have cardiovascular disease: if you could involve them in a program that teaches relaxation, and gets them to move towards a healthier lifestyle, you may find that they're not just feeling better but their disease seems better over time. If you can demonstrate an improvement in blood pressure, other measures of heart disease, and mortality, then you're clearly having a more profound impact beyond the placebo effect. If you have complementary medicine approaches that you think would help for Lupus or for HIV, what actually happens to someone's immune measures is no longer a matter of, "I think this helps" or "This person says they feel better," but you actually have something that would convince the hard scientists that these approaches have validity.

RG: There's been a ground swell of support from Shadyside Hospital and several other foundations to make sure that we'll have all the resources we need to carry out high quality research. We will be seeking federal funding from the National Center for Complementary and Alternative Medicine, which is under the National Institutes of Health. Our goal is to move beyond private funding, which is more in the form of seed grants and start-up money. The federal funding—even though they say they will fund pilot studies—if you have something that nobody's ever done research on before, they're likely to want to see more rationale. That's where having the foundation support can get us started so that two or three years from now we'll have pilot data on different areas to be able to get some of the national funding that's available.

RG: We've been very well-received. My experience before coming to the center has been very favorable. I was the first physician acupuncturist on UPMC Presbyterian's staff and I would get patients referred from surgeons, neurologists, family physicians, sports medicine physicians. The Shadyside community has been very supportive of the center, both patients and physicians. That's really what's kept our center going through the transitions. Obviously, in any medical staff there's going to be some physicians who don't see this as something that would be very beneficial for their patients, and that's understandable. But it seems like the support has been very strong.

RG: Chiropractic is generally covered. Also, psychotherapy services are covered, generally. Acupuncture and the other things like massage and reflexology are typically not covered, so it's an out-of-pocket expense for patients. I think that's going to change. It's changing in California, New York and the east coast. There's an approach to acupuncture that I use called percutaneous electrical nerve stimulation (PENS) and that's really a western medicine technique. There's solid research support for that being beneficial for several different conditions. With that kind of research support, that is the kind of thing that may convince Medicare and other insurers that maybe they should consider paying for complementary therapies and that it might cut down on some of the other treatment expenses—MRIs or even surgeries, conceivably.